National diabetes prevention programmes in LMICs are now a necessity
Authors: Viswanathan Mohan
Journal: The Lancet Global Health (2023)

The prevalence of diabetes is increasing rapidly globally and most of this increase is seen in low-income and middle-income countries (LMICs), where 80% of people with diabetes currently reside. Indeed, China and India alone contribute nearly 40% of the global diabetes burden.1International Diabetes FederationIDF Diabetes Atlas.https://diabetesatlas.org/atlas/tenth-edition/Date: 2021Date accessed: July 27, 2023Google Scholar Type 2 diabetes has a long natural history, with a stage of prediabetes that provides a good opportunity to prevent diabetes. In many countries, the number of people with prediabetes is even higher than the number of people with diabetes. For example, the recent Indian Council of Medical Research–Indian Diabetes national study found that in India there were 101 million people with diabetes, but 136 million people with prediabetes.2Anjana RM Unnikrishnan R Deepa M et al.Metabolic non-communicable disease health report of India: the ICMR-INDIAB national cross-sectional study (ICMR-INDIAB-17).Lancet Diabetes Endocrinol. 2023; 11: 474-489Summary Full Text Full Text PDF PubMed Scopus (0) Google Scholar Large diabetes prevention programmes, such as the Diabetes Prevention Program in the USA,3Diabetes Prevention Program (DPP) Research GroupThe Diabetes Prevention Program (DPP): description of lifestyle intervention.Diabetes Care. 2002; 25: 2165-2171Crossref PubMed Scopus (1566) Google Scholar the Finnish Diabetes Prevention Study in Finland,4Lindström J Louheranta A Mannelin M et al.The Finnish Diabetes Prevention Study (DPS): lifestyle intervention and 3-year results on diet and physical activity.Diabetes Care. 2003; 26: 3230-3236Crossref PubMed Scopus (1017) Google Scholar and the Da Qing study in China,5Pan XR Li GW Hu YH et al.Effects of diet and exercise in preventing NIDDM in people with impaired glucose tolerance: the Da Qing IGT and Diabetes Study.Diabetes Care. 1997; 20: 537-544Crossref PubMed Google Scholar have shown that up to 58% of individuals with prediabetes can be prevented from developing diabetes through intensive lifestyle modification. However, in the Indian Diabetes Prevention Programme, prevention of diabetes was achieved in 28·2%, probably due to lower obesity rates.6Ramachandran A Snehalatha C Mary S Mukesh B Bhaskar AD Vijay V The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1).Diabetologia. 2006; 49: 289-297Crossref PubMed Scopus (1376) Google Scholar Notably, all the above studies only included individuals with impaired glucose tolerance. The Diabetes Community Lifestyle Improvement Program (D-CLIP)7Weber MB Ranjani H Staimez LR et al.The Stepwise approach to diabetes prevention: results from the D-CLIP randomized controlled trial.Diabetes Care. 2016; 39: 1760-1767Crossref PubMed Scopus (108) Google Scholar and the Kerala Diabetes Prevention Program8Thankappan KR Sathish T Tapp RJ et al.A peer-support lifestyle intervention for preventing type 2 diabetes in India: a cluster-randomized controlled trial of the Kerala Diabetes Prevention Program.PLoS Med. 2018; 15e1002575Crossref Scopus (88) Google Scholar showed that in people with impaired fasting glucose, prevention of diabetes was less effective. Thus, in the D-CLIP trial, diabetes was prevented with intensive lifestyle modifications (with additional metformin when indicated) in 31% of people with impaired glucose tolerance, but only in 12% of individuals with impaired fasting glucose.7Weber MB Ranjani H Staimez LR et al.The Stepwise approach to diabetes prevention: results from the D-CLIP randomized controlled trial.Diabetes Care. 2016; 39: 1760-1767Crossref PubMed Scopus (108) Google Scholar Therefore, different approaches might need to be tried to prevent diabetes in people with impaired fasting glucose. Nevertheless, given the large numbers of people with prediabetes in LMICs, unless large scale national prevention programmes are urgently implemented, the number of people with diabetes could become unmanageable. Furthermore, if even a quarter of people with diabetes go on to develop diabetic kidney disease or other complications, the health-care costs could push people into poverty. Dialysis and renal transplantation, the only effective treatments for end-stage renal disease, are affordable for less than 5% of people in LMICs, and the majority of people pay out of pocket for their medical expenses.9Mani MK The management of end stage renal disease in India.Artif Organs. 1998; 22: 182-186Crossref PubMed Scopus (0) Google Scholar With this background, the study by Nicholas Errol Rahim and colleagues10Rahim NE Flood D Marcus ME et al.Diabetes risk and provision of diabetes prevention activities in 44 low-income and middle-income countries: a cross-sectional analysis of nationally representative, individual-level survey data.Lancet Glob Health. 2023; 11: e1576-e1586Google Scholar in The Lancet Global Health is of great interest. The authors report a cross-sectional analysis of nationally representative data in 145 739 adults across 44 LMICs. They included all participants older than 25 years and at high-risk of developing diabetes, who did not currently have diabetes and were not pregnant. High risk was defined as the presence of impaired fasting glucose or overweight or obesity. The authors looked at whether four diabetes prevention activities (physical activity counselling, weight loss counselling, dietary counselling, or blood glucose screening) were included in nationally representative surveys and whether people at high-risk of diabetes received any of these prevention activities. They reported that less than half of individuals in LMICs who are at high risk of diabetes reported receiving diabetes prevention activities. The authors are to be congratulated on compiling such a large dataset evaluating diabetes prevention activities for individuals at high risk of diabetes in LMICs. However, one could argue that the mere inclusion of diabetes prevention counselling activities in national surveys would not really constitute a diabetes prevention programme. The authors do state that 39 of the 44 LMICs included in the study have implemented health systems programmes that include a diabetes prevention component, but I would have liked to see more details of such programmes. Moreover, the authors themselves mention several barriers in the implementation of national diabetes prevention programmes in LMICs, not the least of which is the sheer magnitude of the task, given the huge population of some of these countries. Despite these formidable challenges, it is important to start diabetes prevention programmes that are appropriate to each country. Such efforts would require a multisectoral programme that involves availability and affordability of healthier food choices, promotion of physical activity, and help with weight reduction in individuals with obesity or overweight. Investing in diabetes prevention programmes would be worthwhile and should be done without further delay as non-communicable diseases, such as diabetes, have already overtaken communicable diseases as the major cause of mortality in most LMICs. I declare no competing interests. Diabetes risk and provision of diabetes prevention activities in 44 low-income and middle-income countries: a cross-sectional analysis of nationally representative, individual-level survey dataA large proportion of individuals across LMICs are at high risk of diabetes but less than half reported receiving fundamental prevention activities overall, with the lowest receipt of these activities among people in low-income countries and with no formal education. These findings offer foundational evidence to inform future global targets for diabetes prevention and to strengthen policies and programmes to prevent continued increases in diabetes worldwide. Full-Text PDF Open Access